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Original Investigation |

Observational Modeling of Strict vs Conventional Blood Pressure Control in Patients With Chronic Kidney Disease

Csaba P. Kovesdy, MD1,2; Jun L. Lu, MD2; Miklos Z. Molnar, MD, PhD2; Jennie Z. Ma, PhD3; Robert B. Canada, MD2; Elani Streja, PhD4; Kamyar Kalantar-Zadeh, MD, MPH, PhD4; Anthony J. Bleyer, MD, MS5
[+] Author Affiliations
1Division of Nephrology, Memphis VA Medical Center, Memphis, Tennessee
2Division of Nephrology, University of Tennessee Health Science Center, Memphis
3Division of Nephrology, University of Virginia, Charlottesville
4Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California–Irvine, Orange
5Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
JAMA Intern Med. 2014;174(9):1442-1449. doi:10.1001/jamainternmed.2014.3279.
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Published online

Importance  The effect of strict blood pressure control on clinical outcomes in patients with chronic kidney disease (CKD) is unclear.

Objective  To compare the outcomes associated with a treated systolic blood pressure (SBP) of less than 120 mm Hg vs those associated with the currently recommended SBP of less than 140 mm Hg in a national CKD database of US veterans.

Design, Setting, and Participants  Historical cohort study using a nationwide cohort of US veterans with prevalent CKD, estimated glomerular filtration rate less than 60 mL/min/1.73 m2, and uncontrolled hypertension, who then received 1 or more additional blood pressure medications with evidence of a decrease in SBP. Propensity scores were calculated to reflect each individual’s probability for future SBP less than 120 vs 120 to 139 mm Hg.

Main Outcomes and Measures  The effect of SBP on all-cause mortality was evaluated by the log-rank test, and in Cox models adjusted for propensity scores.

Results  Using a database of 651 749 patients with CKD, we identified 77 765 individuals meeting the inclusion criteria. A total of 5760 patients experienced follow-up treated SBP of less than 120 mm Hg and 72 005 patients had SBP of 120 to 139 mm Hg. During a median follow-up of 6.0 years, 19 517 patients died, with 2380 deaths in the SBP less than 120 mm Hg group (death rate, 80.9/1000 patient-years [95% CI, 77.7-84.2/1000 patient-years]) and 17 137 deaths in the SBP 120 to 139 mm Hg group (death rate, 41.8/1000 patient-years [95% CI, 41.2-42.4/1000 patient-years]; P < .001). The mortality hazard ratio (95% CI) associated with follow-up SBP less than 120 vs 120 to 139 mm Hg was 1.70 (1.63-1.78) after adjustment for propensity scores.

Conclusions and Relevance  Our results suggest that stricter SBP control is associated with higher all-cause mortality in patients with CKD. Confirmation of these findings by ongoing clinical trials would suggest that modeling of therapeutic interventions in observational cohorts may offer useful guidance for the treatment of conditions that lack clinical trial data.

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Figure 1.
Algorithm Used to Define the Study Cohort

BP indicates blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; SBP, systolic blood pressure.

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Figure 2.
Follow-up Systolic Blood Pressure (SBP) and Diastolic Blood Presure (DBP) in Patients With SBP Less Than 120 vs 120 to 139 mm Hg

A, In the overall cohort; B, in the propensity score–matched cohort. Upper symbols show SBP, and lower symbols, DBP. Symbols indicate mean, and error bars, standard deviation.

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Figure 3.
Kaplan-Meier Survival Curves of Patients With Follow-up Systolic Blood Pressure (SBP) Less Than 120 vs 120 to 139 mm Hg
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Figure 4.
Propensity Score–Adjusted Hazard Ratios of All-Cause Mortality Associated With Systolic Blood Pressure Less Than 120 vs 120 to 139 mm Hg in Various Subgroups of Patients in the Overall Cohort

CCI indicates Charlson comorbidity index; and eGFR, estimated glomerular filtration rate. Symbols indicate hazard ratio, and error bars, 95% confidence interval.

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